Repetitive Questioning II.

Repetitive questioning is a major problem for caregivers, particularly taxing if they are unable to recognize and understand the reasons why their loved one keeps asking the same question over and over again. Caregivers may be tempted to believe that the patient does not even try to remember the answer given or is just getting obnoxious. This is incorrect. Repetitive questioning is due to the underlying disease: The patient's short term memory is impaired and he is unable to register, encode, retain and retrieve the answer. If he is concerned about a particular topic, he will keep asking the same question over and over again. To the patient each time she asks the question, it is as if she asked it for the first time. Just answering repetitive questioning by providing repeatedly the same answer is not sufficient. Caregivers should try to identify the underlying cause for this repetitive questioning. In an earlier case study, the patient was concerned about her and her family's safety and kept asking whether the doors are locked. In this present case study, the patient does not know how to handle the awkward situation he finds himself in. He just does not know what to do. He is not able to adjust to the new unexpected situation. So he repeatedly wants to reassure himself that he is not intruding by asking the same question over and over again. We discuss how the patient's son-in-law could have avoided this situation and averted the catastrophic ending.

Repetitive Questioning Exasperates Caregivers.

Repetitive questioning is due to an impaired episodic memory and is a frequent, often presenting, problem in patients with Alzheimer's disease (amnestic type). It is due to the patients' difficulties learning new information, retaining it, and recalling it, and is often aggravated by a poor attention span and easy distractibility. A number of factors may trigger and maintain repetitive questioning. Caregivers should try to identify and address these triggers. In the case discussion presented, it is due to the patient's concerns about her and her family's safety triggered by watching a particularly violent movie aired on TV. What went wrong in the patient/caregiver interaction and how it could have been avoided or averted are explored. Also reviewed are the impact of repetitive questioning, the challenges it raises for caregivers, and some effective intervention strategies that may be useful to diffuse the angst that caregivers experience with repetitive questioning.

Patients with Dementia Are Easily Distracted.

Mild cognitive impairment (MCI) is the middle ground between normal, age-appropriate memory impairment, and dementia. Whereas patients with MCI are able to cope with the memory deficit, those with dementia are not: Their memory impairment and other cognitive deficits are of sufficient magnitude to interfere with the patients' ability to cope independently with daily activities. In both MCI and dementia, there is evidence of declining cognitive functions from a previously higher level of functioning. In both the conditions, there is also an evidence of dysfunction in one or more cognitive domains. There are two subtypes of MCI depending on whether memory is predominantly affected: amnestic type and nonamnestic/behavioral type. Not all patients with MCI transition to dementia, some recover. In this case scenario, we present a 68-year-old man with MCI who lives with his wife. They are getting ready to host dinner. His wife asks him to vacuum the dining room while she runs an urgent errand. We describe how this simple task vacuuming a room ended in a catastrophe with the patient spending the night in jail and his wife hospitalized. We discuss what went wrong in the patient/wife interaction and how the catastrophic ending could have been avoided. OBJECTIVES: At the end of this case discussion readers will know the following:The differences between mild cognitive impairment (MCI), normal aging, and dementia.MCI is often a precursor of dementia and has an amnestic or nonamnestic/behavioral presentation. However, not all patients with MCI develop dementia, some even recover.MCI is an opportunity to discuss with the patient various issues that may arise, should it progress to dementia such as preparing a will, transitioning from driver to passenger, and addressing various financial and legal issues including end-of-life issues and selecting someone to have power of attorney.Patients with MCI should be regularly followed up to determine whether and when they will transition to dementia as this changes the level of care needed.Patients with MCI are at an increased risk of triggering accidents because of their cognitive impairment and often impaired judgment.It may be hazardous to leave patients with MCI alone, without supervision.The importance of support groups, social media, and cameras when providing care to patients with MCI and dementias.

Hallucinations Are Real to Patients With Dementia.

In this case study, we present a patient with preexistent posttraumatic stress disorder and psychosis who has been recently diagnosed with Dementia with Lewy Bodies. He is experiencing vivid hallucinations. What went wrong between him and his wife as a result of these hallucinations is presented. Alternative actions that could have been used are suggested. OBJECTIVES: At the end of this case study, readers will know the following:The characteristic clinical features of Dementia with Lewy Bodies (DLB).Patients experiencing hallucinations should not be contradicted, to them, these hallucinations are real.Easy distractibility and short attention span can be exploited to avert or defuse potentially catastrophic situations.Patients with dementia should not have access to loaded guns.

Patients With Dementia Are Easy Victims to Predators.

Patients with dementia, especially Alzheimer's disease and particularly those in early stages, are susceptible to become victims of predators: Their agnosia (see Case 1) prevents them from detecting and accurately interpreting subtle signals that otherwise would have alerted them that they are about to fall for a scam. Furthermore, their judgment is impaired very early in the disease process, often before other symptoms manifest themselves and usually before a diagnosis is made. Patients with early stages of dementia are therefore prime targets for unscrupulous predators, and it behooves caregivers and health care professionals to ensure the integrity of these patients. In this case study, we discuss how a man with mild Alzheimer's disease was about to fall for a scam were it not for his vigilant wife. We discuss what went wrong in the patient/caregiver interaction and how the catastrophic ending could have been avoided or averted.

Too Many Choices Confuse Patients With Dementia.

Choices are often difficult to make by patients with Alzheimer Dementia. They often become acutely confused when faced with too many options because they are not able to retain in their working memory enough information about the various individual choices available. In this case study, we describe how an essentially simple benign task (choosing a dress to wear) can rapidly escalate and result in a catastrophic outcome. We examine what went wrong in the patient/caregiver interaction and how that potentially catastrophic situation could have been avoided or defused.

Axotomy-induced loss of m2 muscarinic receptor mRNA in the rat facial motor nucleus precedes a decrease in concentration of muscarinic receptors.

The abundance of muscarinic receptors and m2 muscarinic receptor mRNA in the facial nuclei of rats was evaluated by autoradiographic procedures at various times up to 14 days after transection of the right facial nerve. Receptors were labelled by in vitro incubation of brain sections with L-[3H]quinuclidinyl benzilate, while in situ hybridization with a 35S-labelled oligonucleotide was used to identify m2 muscarinic receptor mRNA in neighbouring sections. The right and left facial nuclei of non-operated control rats appeared equivalent in abundance of muscarinic receptors (359 +/- 8 versus 376 +/- 9 fmol per mg tissue, n = 5) and the presence of m2 mRNA. Axotomy had no effect on the concentration of receptors in the contralateral facial nucleus but caused a gradual loss of receptors from the ipsilateral side. No change was detected at 1 day after nerve transection, but a 23% decrease relative to the contralateral facial nucleus had occurred by 3 days. A maximum decrease of 51% was achieved by 1 week after nerve transection. By comparison, m2 mRNA was nearly eliminated from the ipsilateral facial nucleus at 1 day post-taxonomy and remained depleted for the duration of study. Previous work has established that no significant loss of motoneurons occurs within this period. Accordingly, it is postulated that axonal injury inhibits transcription of the m2 muscarinic receptor gene, resulting in a later decrease in muscarinic receptor protein expression.

Bilateral adrenal hemorrhage after blunt trauma: diagnosis by computed tomography.

The patient described here had bilateral adrenal hemorrhage due to blunt trauma from a motor vehicle accident. At no time during the patient's hospitalization nor in the year since the accident has he had signs or symptoms suggestive of adrenal insufficiency. The diagnosis of adrenal hemorrhage was made on the basis of changes seen on initial abdominal computed tomography. A 26% incidence of adrenal hemorrhage in patients dying after severe trauma has been established from postmortem examinations, but the overall incidence in trauma patients is not known. Abdominal CT scans may show this entity where it otherwise might not be suspected, particularly since adrenal insufficiency is infrequent.

Rattlesnake bite of the face: case report and review of the literature.

Most poisonous snakebites with envenomation involve the extremities. A case where the bite occurred on the face is presented. Problems in management included marked coagulopathy and prolonged airway compromise, requiring 9 days of nasotracheal intubation. The bite site did not develop necrosis and required only local wound care.